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Surgical Management of Gingival Recession Using Free Gingival Autograft: A

Case Report

Article  in  Journal of Nepalese Society of Periodontology and Oral Implantology · December 2019

DOI: 10.3126/jnspoi.v3i2.30890

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Case Report J Nepal Soc Perio Oral Implantol. 2019;3(6):81-3

Surgical Management of Gingival Recession Using Free Gingival

Autograft: A Case Report

Dr. Manisha Neupane,1 Dr. Manoj Humagain,1 Dr. Mahima Subba,1

Dr. Simant Lamichhane,1 Dr. Asmita Dawadi1
1
Department of Periodontology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal.

ABSTRACT
Gingival recession leads to dentinal hypersensitivity, aesthetic problems, root caries, cervical abrasion and difficulty in oral hygiene
maintenance. Managing gingival recession often is a great challenge for practitioners. Different surgical techniques have been advocated
for root coverage like free soft tissue graft procedures free gingival graft and sub-epithelial connective tissue graft, pedicle soft tissue
graft rotational flap and flap advancement, pouch and tunnel technique and guided tissue regeneration. This case report displays use of
free gingival graft for management of patient of age 22 years with Miller’s Class I recession defect in lower left mandibular central incisor.

Keywords: Free gingival autograft; gingival recession; root coverage.

INTRODUCTION Patient underwent on fixed orthodontic therapy two years

back for correction of crowded upper and lower teeth. On
Globally, around 50 % of individuals suffers from gingival
examination, the oral hygiene status was fair with moderate
recession1 and in Nepal about 65%.2 Prevalence increases
deposition of plaque and calculus and presence of recession
with age and is common in mandibular teeth than maxillary
of Miller’s Class I6 was noted with respect to #31 (Figure: 4)
with thicker and wider keratinised tissues.2 For management
having a thin gingival biotype and high lower lip line.
of recession, several surgical techniques are applied: free
During 1st visit, full mouth scaling was done and modified
gingival graft (FGG), sub-epithelial connective tissue graft,
Stillman’s method of toothbrushing was demonstrated. The
laterally-positioned graft, double-papilla flap, pouch and
recession noted was ‘U’ type recession7 with 3 mm apico-
tunnel technique and guided tissue regeneration.3 FGG,
coronal height and 3 mm mesio-distal width at greatest
first described by Bjorn et al. (1963),4 to increase width
dimension (Figure 2, 3). The single-stage surgical technique
of attached gingiva and deepening of sulcus. Mean root
using free gingival autograft was explained on the same
coverage percentage ranges from 43%-85.3%.5 However,
day. On the next visit after one month, written consent was
meticulous surgical procedure can ensure success rate of
taken and the surgical procedure was carried out as follows:
FGG towards higher side.
Preparation of recipient bed: The area was anaesthesized
CASE REPORT
by use of local infiltration technique with 2% Lignocaine
A 22-year-old male patient reported to the Department of HCl + 1:2,00,0000 epinephrine. The peripheral gingival
Periodontology, Dhulikhel hospital with a chief complaint of tissues surrounding the recession was de-epithelialised
downward shifting of gum in lower front teeth region which
was progressive in nature and causing tooth sensitivity
(Figure: 1). Medical history revealed no obvious findings.

Correspondence:
Dr. Manisha Neupane
Department of Periodontology, Kathmandu University School of
Medical Sciences, Dhulikhel, Kavre, Nepal.
email: manissaa@gmail.com

Citation
Neupane M, Humagain M, Subba M, Lamichhane S, Dawadi A.
Surgical Management of Gingival Recession using Free Gingival
Autograft: A Case Report. J Nepal Soc Perio Oral Implantol.
2019;3(6):81-3. Figure 1: Pre-surgical view.

Journal of Nepalese Society of Periodontology and Oral Implantology :Vol. 3, No. 2, Issue 6, Jul-Dec, 2019 81
Neupane et al. : Surgical Management of Gingival Recession Using Free Gingival Autograft: A Case Report

Figure 2: M-D dimension of recession (3 mm). Figure 3: Apico-coronal height of recession (3 mm). Figure 4: Intra-oral periapical radiograph.

Figure 5: Recipient bed preparation. Figure 6: Tin foil template(15×7 mm). Figure 7: Harvested FGG from palate.

after scaling and root planing was performed. Lower lip with haemostatic sponge for haemostasis and Hawley’s
was then retracted and initial incision was made at the retainer was placed.
existing mucogingival junction using #15 BP blade. A
Graft preparation: The underside of graft was inspected for
sharp dissection was continued 6 mm apically and deep
the presence of any fatty or glandular tissues. The tissue
to compensate for graft healing and shrinkage. Thus, a
tags and fatty tissues were removed and graft of uniform
recipient bed measuring approximately 12×6 mm was
thickness of about 1.5 mm thickness was prepared using
prepared ready to receive the graft (Figure: 5).
#15 scalpel (Figure:7).
Obtaining the graft from donor site: The graft was planned
Graft placement: The graft was then placed on the recipient
to be retrieved from distal to anterior palatine rugae area
bed and secured first by use of two interrupted 4-0 silk
with respect to tooth number 24, 25, and 26. Greater
sutures at the mesial and distal aspects. Then,graft was
palatine nerve block was given using same anaesthetic
fully stabilized by use of criss-cross suture and re-inforced
solution as used for the recipient site. Tin foil template of
interrupted sutures. Slight pressure was applied with saline
15×7 mm was placed on the donor site and bleeding points
moistened gauze for 5 minutes to achieve haemostasis
were induced (Figure: 6). Partial thickness dissection was
and formation of fibrin clot. The surgical site was then
done to retrieve the FGG from the donor area. Thus, a graft
well-protected using tin foil and non-eugenol periodontal
was obtained from the palate. The donor site was covered
dressing. (Figure: 8,9)

Figure 8: FGG secured with suture. Figure 9: Graft completely sutured to recipient bed. Figure 10: Post-operative view at 1 month.

82 Journal of Nepalese Society of Periodontology and Oral Implantology :Vol. 3, No. 2, Issue 6, Jul-Dec, 2019
 Neupane et al. : Surgical Management of Gingival Recession Using Free Gingival Autograft: A Case Report

Post-surgical instructions: The patient was instructed to
refrain from tooth brushing at the surgical site for 10 days.
Chlorhexidine mouthwash 0.2% 10ml twice daily for 10 days
along with Amoxicillin 500 mg thrice daily + Metronidazole
400mg thrice daily for 5 days and Analgesics as per needed
was prescribed. Patient follow up visit was scheduled after
10 days of surgery.
Suture removal and post-operative healing: Non-eugenol
periodontal dressing and sutures were removed followed by
irrigation with normal saline. The recipient site and donor
site healing was satisfactory. At the one month follow-up,
both recipient site and donor site were completely healed &
desired results were obtained (Figure 10).
DISCUSSION
Gingival recession is displacement of gingival margin
apical to cemento-enamel junction leading to exposure of
root surface and posing various deformities like dentinal
hypersensitivity, root caries and aesthetic compromise.
Common etiologies for most of the recession are increasing
age, masochistic habits, injudicious orthodontic forces,
periodontal surgery, periodontal diseases and abnormal
frenal attachments. For management of gingival recession,
several surgical techniques are being clinically applied
like FGG, sub-epithelial connective tissue graft, laterally
positioned graft, double papilla flap, pouch and tunnel
technique and guided tissue regeneration.3
Due to its wide variety of use, FGG is commonly practiced
technique for many decades. It was used basically for
management of inadequate width of attached gingiva
and inadequate vestibular depth. The advantage with
this technique is that it offers root coverage in addition
whenever attempt to augment keratinised gingiva is
done. Technique sensitive, high patient
trauma during healing, open raw wound at donor site and
unpredictable colour match are the major drawbacks of
FGG. There are different schools of thoughts for thickness
of graft. Soehren and colleagues in 1973 advocated the use
of partial to intermediate thickness graft of 0.5-0.75 mm
as the ideal graft for FGG believing there is less primary
contraction due to less amount of elastic fibers in thin
graft.8 However, results by Ratertschak, Siebert and Ward
observation revealed the secondary contraction of thin
grafts due to cicatrisation during uptake of graft by tissues.9
Thus, the ideal full thickness graft as described by Sullivan
and Atkins back in 1968 still holds true for successful
healing and ideal results.10 This case report depicts the
successful use of FGG as described by Miller’s criteria for
successful root coverage. The soft tissue margin must be
at the cementoenamel junction, there is clinical attachment
to the root, the sulcus depth is two mm or less and there
is no bleeding on probing. The root coverage achieved in
this case was almost 67% which corresponds to results
achieved on average which was 64% as per systematic
review on perioplastic surgery done by Roccuzzo.5 Also, the
thick biotype keratinised gingiva was the end result after
first month of surgery. A recession coverage with one mm
creeping attachment over a one year period post-surgery is
anticipated.
SUMMARY
Among all root coverage techniques sub-epithelial
connective tissue graft is considered as the “gold standard.”
FGG still is a flexible and multipurpose technique for root
coverage in areas with recession, inadequate width of
attached gingiva, shallow vestibular depth and in areas
where aesthetics is not a major concern.
Conflict of Interest: None
compliance,

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2. Humagain M, Kafle D. The Evaluation of Prevalence, Extension and Severity of Gingival Recession among Rural Nepalese Adults. Orthod
J Nepal. 2013;3(1):41-6.
3. Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: root coverage revisited. Periodontology 2000. 2001;27:97-120.
4. Takei HH, Azzi RR, Han TJ. Periodontal plastic and aesthetic surgery. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors.
Carranza’s Clinical Periodontology 10th ed. St. Louis, MO: Saunders Elsevier; 2006. p1008
5. Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localised gingival recessions: a systematic
review. J Clin Periodontol. 2002; 29(Suppl. 3):178-194.
6. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.
7. Benque EP, Brunel G, Gineste M, Colin L, Duffort J, Fonvielle E. Gingival recession. Parodontol J. 1984;3:207-41.
8. Sohren SE, Allen AL, Cutright DE, Seibert JS. Clinical and histologic studies of donor tissues utilised for free grafts of masticatory
mucosa. J Periodontol. 1973;44(12):727-41.
9. Cohen ES. Atlas of cosmetic and reconstructive periodontal surgery. 3rd ed. Ontario, Canada: BC Decker Inc.; 2007. p57
10. Sullivan HC, Atkins JH. Free autogenous gingival grafts. 1. Principles of successful grafting. Periodontics. 1968;6(1):5-13.

Journal of Nepalese Society of Periodontology and Oral Implantology :Vol. 3, No. 2, Issue 6, Jul-Dec, 2019 83
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